{php}
$names = array();
$names[] = "General";
$names[] = "HEENT";
$names[] = "Oral";
$names[] = "Neck_Thyroid";
$names[] = "Heart";
$names[] = "Chest_Lungs";
$names[] = "Breast_Exam";
$names[] = "Abdomen";
$names[] = "GU";
$names[] = "Back";
$names[] = "MS_Extremeties";
$names[] = "LEAP";
$names[] = "Neuro";
$names[] = "Skin";

$this->assign("names_array",$names);

{/php}
<div id="postResults"></div>
<form action='{$base_uri}index.php/WidgetForm/Fillout/{$formId}' id="ajaxForm{$formId}" method="post">
{if $open}
<input type="button" onClick="formSubmit({$formId});" value="Update" />
{/if}
<input type="hidden" name="form_id" value="{$formId}" />
<input type="hidden" name="process" value="true" />
<input type="hidden" name="filloutType" value="encounter" />
			<div style="clear: both;"></div>
                        <table class="grid">
			<thead>
				<tr><th></th><th>Condition</th><th>Comments</th></tr>
			</thead>

			<tbody>
				{foreach from=$names_array item=name}
	                        <tr class="alt"><td>{$name}</td>
					<td>{input type="radio" name="phys_exam_`$name`" value="normal" options="Normal" display="horizontal"}<br>
					{input type="radio" name="phys_exam_`$name`" value="abnormal" options="Abnormal" display="horizontal"}<br>
					{input type="radio" name="phys_exam_`$name`" value="not_assessed" options="Not Assessed" display="horizontal"}</td>
			<td>{input type="text" cols="30" rows="5" name="phys_exam_`$name`_note"}</td></tr>
				{/foreach}
			</tbody>
                        </table>
</form>
